Anesthetic Events Research Articles

Preliminary Clinical Comparison of Anesthesia with Ketamine/Medetomidine and S-Ketamine/Medetomidine in Testudo spp.

Abstract A prospective, randomized, crossover experimental pilot study was performed to compare the anesthetic quality and recovery times of intramuscular (IM) ketamine/medetomidine and S-ketamine/medetomidine in Testudo spp. Four adult male Hermann's tortoises (Testudo hermanni) and one adult male spur-thighed tortoise (Testudo graeca) were used in this study. Each animal underwent two different anesthetic protocols twice, with a washout period of two weeks in between each anesthetic event. This resulted in 20 anesthetic procedures. Protocols consisted of 0.1 mg/kg medetomidine IM with either 15 mg/kg ketamine (KM) or 15 mg/kg S-ketamine (SKM). After 60 min, medetomidine was reversed using 0.5mg/kg atipamezole IM. Muscle relaxation, ease of handling, sensitivity to a painful stimulus, palpebral and corneal reflexes, heart rate (HR), and respiratory rate (RR) were measured every 15 min during anesthesia. Time of initial effect, maximal anesthetic effect, first movements, complete wakefulness, first feedin...

Local Anesthetic Systemic Toxicity: A Review of Recent Case Reports and Registries.

This review summarizes presenting features, management, and outcomes of local anesthetic systemic toxicity (LAST) from published cases and those submitted to online registries capturing use of intravenous lipid emulsion (ILE) therapy. The results of single-center and multicenter registries and epidemiologic studies complement this information. Between March 2014 and November 2016, 47 separate cases of LAST were described in 35 peer-reviewed articles. Local anesthetic systemic toxicity events occurred as a result of penile blocks (23%), local infiltration (17%), and upper/lower extremity, torso, and neuraxial blockade. Twenty-two patients (47%) were treated with ILE, and 2 patients (4.3%) died. During the same time period, 11 cases submitted to lipidrescue.org were treated with ILE and survived. The incidence of LAST reported in registries is 0.03% or 0.27 (95% confidence interval, 0.21-0.35) per 1000 peripheral nerve blocks (denominator of 251,325). Seizure (53% and 61% from case reports and registries, respectively) was the most common presenting feature.

Efficacy of favipiravir (T-705) in nonhuman primates infected with Ebola virus or Marburg virus

Favipiravir is a broad-spectrum antiviral agent that has demonstrated efficacy against Ebola virus (EBOV) in rodents. However, there are no published reports of favipiravir efficacy for filovirus infection of nonhuman primates (NHPs). Here we evaluated the pharmacokinetic profile of favipiravir in NHPs, as well as in vivo efficacy against two filoviruses, EBOV and Marburg virus (MARV). While no survival benefit was observed in two studies employing once- or twice-daily oral dosing of favipiravir during EBOV infection of NHPs, an antiviral effect was observed in terms of extended time-to-death and reduced levels of viral RNA. However, oral dosing in biosafety level-4 (BSL-4) presents logistical and technical challenges, and repeated anesthesia events may potentially worsen survival outcome in animals. For the third study of treatment of MARV infection, we therefore made use of catheters, jackets, and tethers for intravenous (IV) dosing and blood collection, which minimized the requirement for repeated anesthesia events. When MARV infection was treated with IV favipiravir, five of six animals (83%) survived infection, while all untreated NHPs succumbed. An accompanying report presents the results of favipiravir treatment of EBOV infection in mice.

Dose-response studies of Ropivacaine in blood flow of upper extremity after supraclavicular block: a double-blind randomized controlled study

BackgroundThe sympathetic block of upper limb leading to increased blood flow has important clinical implication in microvascular surgery. However, little is known regarding the relationship between concentration of local anesthetic and blood flow of upper limb. The aim of this dose–response study was to determine the ED50 and ED95 of ropivacaine in blood flow after supraclavicular block (SB).MethodsPatients undergoing upper limb surgery and supraclavicular block were randomly assigned to receive 30ml ropivacaine in concentrations of 0.125%(A Group), 0.2%(B Group), 0.25%(C Group), 0.375%(D Group), 0.5%(E Group), or 0.75%(F Group) (n=13 per group). All patients received supraclavicular block (SB). Time average maximum velocity (TAMAX), cross-sectional area (CSA) of brachial artery and skin temperatures (Ts) were measured repeatedly at the same marked points, they were taken at baseline (before block, t0) and at 30min after SB (t1). Blood flow(BF) = TAMAX× CSA×60 sec.. Relative blood flow (ΔBF) = BFt1/ BFt0. Success of SB was assessed simultaneously. Supplementary anesthesia and other adverse events (AE) were recorded.ResultsSignificant increase in TAMAX, CSA, BF and Ts were seen in all concentration groups at t1 comparing with t0 (P<0.001). There was an upward trend of TAMAX, CSA, BF with the increasing concentration of ropivacaine except Ts. There was no significant different of Ts at t1 among different concentration group. The dose-response formula of ropivacaine on ΔBF was Y=1+3.188/(1+10^((−2.451-X) × 1.730)) and ED50/ED95 (95%CI) were 0.35/1.94%(0.25–0.45/0.83–4.52), and R2 (coefficient of determination) =0.85. ED50/ED95 (95%CI) values of sensory block were 0.18/0.33% (0.15–0.21/0.27–0.51), R2=0.904.ConclusionsThe dose-response curve between SB ropivacaine and the changes of BF was determined. The ED50/ED95 of ropivacaine of ΔBF are 0.35/1.94% (0.25–0.45/0.83–4.52). TAMAX, CSA and BF consistently increased with ropivacaine concentration. The maximal sympathetic block needs higher concentration than that complete sensation block needs which may benefit for microvascular surgery.Trial registrationClinicaltrials.govNCT02139982. Retrospectively registered (Date of registration: May, 2014).

Administration of anaesthetic triggering agents to patients tested malignant hyperthermia normal and their relatives in New Zealand: an update.

Testing for malignant hyperthermia in New Zealand involves two tests-in vitro contracture testing of excised lateral quadriceps muscle and DNA analysis. In vitro contracture testing is regarded as the gold standard in malignant hyperthermia diagnosis but several publications have questioned the reliability of a normal result. Analysis of 479 anaesthetic records in 280 patients or their descendants throughout New Zealand who had tested negative for malignant hyperthermia, demonstrated there was no evidence of malignant hyperthermia episodes in this group who had been administered anaesthetic triggering agents. A wide range of anaesthetics were used over the study period. Analysis of each anaesthetic record was undertaken using the malignant hyperthermia grading scale which determines the likelihood that an anaesthetic event represents a malignant hyperthermia episode. Confirmation of the negative results was further supported by normal DNA analysis of patients in 48% of anaesthetics. There are advantages to using inhalational agents in certain situations and although demonstrating a zero risk of a malignant hyperthermia episode is not statistically possible, evidence in this large series suggests that the risk of an episode in these patients is extremely low and may be negligible. We suggest that anaesthetic triggering agents can be used safely in patients with normal in vitro contracture tests, and in their descendants.

Perioperative and Anesthetic Adverse events in Thailand (PAAd Thai) incident reporting study: anesthetic profiles and outcomes

Background: The Royal College of Anesthesiologists of Thailand initiated registry and reporting of anesthesia service incidents and outcomes in 2005. Objectives: The Perianesthetic Anesthetic Adverse Events in Thailand (PAAd Thai) study aimed to investigate patient, surgical, and anesthetic profiles, and suggest strategies for prevention of adverse events. Methods: A prospective descriptive study was conducted in 22 hospitals across Thailand. Each hospital was invited to report, on an anonymous basis, any perianesthetic adverse incident during 12 months (between January 1 and December 31, 2015). A standardized incident report form was completed to determine the type of incident, and where, when, how, and why it occurred using closed and open-ended questionnaires. Data regarding main anesthetic techniques were also reported monthly. Descriptive statistics were used. Results: For 333,219 cases, 2,206 incident reports with 3,028 critical incidents were reported. The incidents commonly occurred in male patients (52.0%), aged 70 y (18.2%). The incidence of adverse events included cardiac arrest within 24 h (15.5:10,000), death (13.0:10,000), reintubation (11.1:10,000), esophageal intubation (8.5:10,000), difficult intubation (8.0:10,000), and malignant hyperthermia (1:200,000). General, cardiothoracic, neurological, and otorhinolaryngological surgical specialties posed a high risk of incidents. Operating and recovery rooms were common locations for incidents. Conclusion: In the past decade, there were dramatic reductions of perioperative cardiac arrests and difficult intubations. Common factors related to critical incidents were inexperience, emergency, inadequate preanesthetic evaluation, inappropriate decisions, lack of vigilance, and inexperienced assistants. Suggested corrective strategies are compliance with guidelines, additional training, and improvement of supervision and quality assurance. Keywords: Adverse events, anesthesia, incidents, incident report, patient safety

Immersıon Anesthesia with Alfaxalone in a Goldfısh (Carassius auratus)

An alfaxalone anesthesia protocol was used to perform a coeliotomy in a goldfish diagnosed with multiple ovarian cysts. The 7-year-old, 460g, female goldfish presented for severe coelomic distension and anorexia. Full-body radiographic images were unremarkable, but coelomic ultrasound revealed multiple ovarian cysts. Ultrasound-guided aspiration of a large cyst was performed. Cytology revealed lysed leukocytes that contained numerous intracellular bacilli suggestive of septic suppurative inflammation. An exploratory coeliotomy was performed and 90mL of semi-clear fluid was aspirated from the largest cysts. For anesthesia, three plastic fish tanks were prepared for induction (10mg/L of alfaxalone), maintenance (5mg/L alfaxalone), and recovery (no anesthetic agent). Water in the fish tanks was saturated with oxygen. The goldfish was immersed in the induction tank and once the labyrinthine-righting reflex was lost (5 minutes), the fish was placed in the maintenance tank. The goldfish was then placed on a platform and supported in a supine position on wet Perlon wool. The head of the goldfish was submerged in water while the coelomic area of the surgical field was maintained out of water. During surgery, the respiratory rate (32 to 53 opercula movements per minute) and heart rate (35 to 45beats per minute) were monitored. Butorphanol (0.4mg/kg IM) was administered for analgesia. The anesthetic event was 60 minutes, with the recovery period being 35 minutes. There were no complications associated with recovery and the goldfish returned to its normal position 12 hours after surgery. Immersion anesthesia with alfaxalone permitted deep anesthesia for surgery with an uncomplicated recovery. The anesthetic protocol described appears to be a safe and easy protocol for general practitioners and, furthermore, uses anesthetic agent commonly available to veterinarians.

Efficiency of laparoscopic vs. endoscopic management in cholelithiasis and choledocholithiasis. Is there any difference?

Abstract Background Concomitant cholelithiasis and choledocholithiasis is a disease where incidence increases with age and can have serious complications such as pancreatitis, cholangitis and liver abscesses, but its management is controversial, because there are minimally invasive laparoscopic and endoscopic surgical procedures. Objective To compare the efficiency in the management of cholelithiasis and choledocholithiasis with laparoscopic cholecystectomy with common bile duct exploration vs. cholangiopancreatography endoscopic retrograde + laparoscopic cholecystectomy. Material and method Retrospective analysis of a five year observational, cross sectional multicenter study of patients with cholelithiasis and concomitant high risk of choledocholithiasis who were divided into two groups and the efficiency of both procedures was compared. Group 1 underwent laparoscopic cholecystectomy with common bile duct exploration and group 2 underwent cholangiopancreatography endoscopic retrograde + laparoscopic cholecystectomy. Results 40 patients, 20 were included in each group, we found p = 0.10 in terms of operating time; when we compared hospital days we found p = 0.63; the success of stone extraction by study group we obtained was p = 0.15; the complications presented by group was p = 0.1 and the number of hospitalizations by group was p ≤ 0.05 demonstrating statistical significance. Conclusions Both approaches have the same efficiency in the management of cholelithiasis and choledocholithiasis in terms of operating time, success in extracting stone, days of hospitalization, postoperative complications and conversion to open surgery. However the laparoscopic approach is favourable because it reduces the number of surgical anaesthetic events and the number of hospital admissions.

Using High-Technology Simulators to Prepare Anesthesia Providers Before Implementation of a New Electronic Health Record Module: A Technical Report.

Learning to use a new electronic anesthesia information management system can be challenging. Documenting anesthetic events, medication administration, and airway management in an unfamiliar system while simultaneously caring for a patient with the vigilance required for safe anesthesia can be distracting and risky. This technical report describes a vendor-agnostic approach to training using a high-technology manikin in a simulated clinical scenario. Training was feasible and valued by participants but required a combination of electronic and manual components. Further exploration may reveal simulated patient care training that provides the greatest benefit to participants as well as feedback to inform electronic health record improvements.

Outcome and complications in dogs with appendicular primary bone tumors treated with stereotactic radiotherapy and concurrent surgical stabilization

To document the outcome of dogs with appendicular primary bone tumors treated with stereotactic radiotherapy (SRT) and concurrent stabilization. Multi-institutional retrospective case series. Eighteen dogs with presumptive or definitive diagnosis of appendicular osteosarcoma. Medical records of dogs with appendicular primary bone tumors treated with SRT and stabilization were reviewed for signalment, preoperative staging and diagnostics, radiation dose, stabilization method, and outcome. The distal radius was affected in 13/18 cases. Osteosarcoma or sarcoma was confirmed cytologically or histologically in 15/18 cases. Seven dogs were diagnosed with a pathological fracture at the time of treatment, and 11 were considered at high risk for pathological fracture. Dogs received a single dose (n = 5) or 3 doses (n = 13) of SRT. Surgical stabilization was performed under the same anesthetic event as the final dose of SRT in 10 dogs. Stabilization was achieved with a bone plate (n = 15) or interlocking nail (n = 3). Seventeen dogs received adjuvant chemotherapy. Complications occurred in 16/17 dogs, 15/17 of those being considered major complications. Four dogs experienced more than one complication. Infection was the most common complication, diagnosed in 15/17 cases, and considered as a major complication in 13/15 cases. Postoperative fracture was recorded as a major complication in 3 cases. Nine dogs were amputated at a median of 152 days. The median survival time was 344 days. Treatment of bone tumors with SRT and concurrent stabilization was associated with a prohibitively high complication rate in dogs. Alternative methods for limb salvage should be considered for dogs at risk for pathologic fracture.

Pediatric Cardiopulmonary Arrest in the Postanesthesia Care Unit, Rare but Preventable: Analysis of Data From Wake Up Safe, The Pediatric Anesthesia Quality Improvement Initiative.

Nearly 20% of anesthesia-related pediatric cardiac arrests (CAs) occur during emergence or recovery. The aims of this case series were to use the Wake Up Safe database to describe the following: (1) the nature of pediatric postanesthesia care unit (PACU) CA and subsequent outcomes and (2) factors associated with harm after pediatric PACU CA. Pediatric CAs in the PACU were identified from the Wake Up Safe Pediatric Anesthesia Quality Improvement Initiative, a multicenter registry of adverse events in pediatric anesthesia. Demographics, underlying conditions, cause of CA, and outcomes were extracted. Descriptive statistics were used to characterize data and to assess risk of harm in those suffering CA. A total of 26 CA events were included: 67% in children <5 years, and 30% in infants (<1 year); 18 (69%) were deemed likely or almost certainly preventable. All preventable CAs were respiratory in nature and most (67%) had purported root causes that included provider judgment or inexperience, inadequate supervision, and competing priorities. CAs of cardiac origin were associated with increased level of harm (temporary or greater), whereas those of respiratory origin were associated more often with no harm. PACU CA events are rare and generally survivable, with better outcomes for respiratory-based events, but most were deemed preventable, suggesting a need for further vigilance in the early postoperative period. Maintenance of monitoring during patient transport to PACU and continuing care by anesthesia care providers until emergence from anesthesia may further reduce the preventable arrest rate. The root cause analyses conducted by individual institutions reporting these data to the Wake Up Safe provided only limited insight, so multicenter collaborative approaches may allow for greater insight into effective CA-prevention strategies.

Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe

Little is known about the incidence of severe critical events in children undergoing general anaesthesia in Europe. We aimed to identify the incidence, nature, and outcome of severe critical events in children undergoing anaesthesia, and the associated potential risk factors. The APRICOT study was a prospective observational multicentre cohort study of children from birth to 15 years of age undergoing elective or urgent anaesthesia for diagnostic or surgical procedures. Children were eligible for inclusion during a 2-week period determined prospectively by each centre. There were 261 participating centres across 33 European countries. The primary endpoint was the occurence of perioperative severe critical events requiring immediate intervention. A severe critical event was defined as the occurrence of respiratory, cardiac, allergic, or neurological complications requiring immediate intervention and that led (or could have led) to major disability or death. This study is registered with ClinicalTrials.gov, number NCT01878760. Between April 1, 2014, and Jan 31, 2015, 31 127 anaesthetic procedures in 30 874 children with a mean age of 6·35 years (SD 4·50) were included. The incidence of perioperative severe critical events was 5·2% (95% CI 5·0-5·5) with an incidence of respiratory critical events of 3·1% (2·9-3·3). Cardiovascular instability occurred in 1·9% (1·7-2·1), with an immediate poor outcome in 5·4% (3·7-7·5) of these cases. The all-cause 30-day in-hospital mortality rate was 10 in 10 000. This was independent of type of anaesthesia. Age (relative risk 0·88, 95% CI 0·86-0·90; p<0·0001), medical history, and physical condition (1·60, 1·40-1·82; p<0·0001) were the major risk factors for a serious critical event. Multivariate analysis revealed evidence for the beneficial effect of years of experience of the most senior anaesthesia team member (0·99, 0·981-0·997; p<0·0048 for respiratory critical events, and 0·98, 0·97-0·99; p=0·0039 for cardiovascular critical events), rather than the type of health institution or providers. This study highlights a relatively high rate of severe critical events during the anaesthesia management of children for surgical or diagnostic procedures in Europe, and a large variability in the practice of paediatric anaesthesia. These findings are substantial enough to warrant attention from national, regional, and specialist societies to target education of anaesthesiologists and their teams and implement strategies for quality improvement in paediatric anaesthesia. European Society of Anaesthesiology.

The hairy lizard: heterothermia affects anaesthetic requirements in the Arabian oryx (Oryx leucoryx)

ObjectiveTo study the effect of heterothermia on anaesthetic drug requirements in semi-free ranging Arabian oryx and to assess the temperature quotient (Q10) of oxygen consumption. Study designProspective observational study and controlled metabolic experiment. AnimalsSixty-eight anaesthetic events in 59 Arabian oryx from Mahazat As-Sayd protected area, Saudi Arabia MethodsAnaesthesia was induced by remote injection of 25 mg ketamine, 10 mg midazolam and 0.5 mg medetomidine with a variable amount of etorphine based on a target dosage of 20 μg kg–1 and subjective assessment of body mass. Animals not recumbent within 15 minutes or insufficiently anaesthetized were physically restrained and administered supplementary etorphine intravenously depending on the anaesthetic depth. Body temperature (Tb) was measured rectally immediately upon handling of each animal. From six anaesthetized oryx, expiratory gasses for oxygen analysis and metabolic rate calculation were collected at two Tbs; before and after submersion in ice water for approximately 30 minutes. ResultsForty-two animals (62%) became recumbent with the initial dose, with a mean induction time (± standard deviation) of 9 ± 2 minutes. The remaining animals could be handled but needed 0.3 ± 0.1 mg etorphine intravenously to reach the desired level of anaesthesia. There was a significant positive correlation between Tb and effective etorphine dosage (R2 = 0.48, p < 0.0001). Average Tb of the six animals in which metabolic rate was measured decreased from 40.0 ± 0.5°C immediately after induction to 35.5 ± 0.5°C after cooling. This reduction was associated with a reduction in oxygen uptake from 3.11 ± 0.33 to 2.22 ± 0.29 mL O2 minute–1 kg–1, reflected in Q10 of 2.17 ± 0.14. Conclusions and clinical relevanceTb significantly affects anaesthetic requirements in Arabian oryx and should be considered when selecting dosages for anaesthetic induction for species showing diurnal heterothermy.

The Development and Implementation of Cognitive Aids for Critical Events in Pediatric Anesthesia: The Society for Pediatric Anesthesia Critical Events Checklists

Cognitive aids such as checklists are commonly used in modern operating rooms for routine processes, and the use of such aids may be even more important during critical events. The Quality and Safety Committee of the Society for Pediatric Anesthesia (SPA) has developed a set of critical-event checklists and cognitive aids designed for 3 purposes: (1) as a repository of the latest evidence-based and expert opinion-based information to guide response and management of critical events, (2) as a source of just-in-time information during critical events, and (3) as a method to facilitate a shared understanding of required actions among team members during a critical event. Committee members, who represented children's hospitals from across the nation, used the recent literature and established guidelines (where available) and incorporated the expertise of colleagues at their institutions to develop these checklists, which included relevant factors to consider and steps to take in response to critical events. Human factors principles were incorporated to enhance checklist usability, facilitate error-free accomplishment, and ensure a common approach to checklist layout, formatting, structure, and design.The checklists were made available in multiple formats: a PDF version for easy printing, a mobile application, and at some institutions, a Web-based application using the anesthesia information management system. After the checklists were created, training commenced, and plans for validation were begun. User training is essential for successful implementation and should ideally include explanation of the organization of the checklists; familiarization of users with the layout, structure, and formatting of the checklists; coaching in how to use the checklists in a team environment; reviewing of the items; and simulation of checklist use. Because of the rare and unpredictable nature of critical events, clinical trials that use crisis checklists are difficult to conduct; however, recent and future simulation studies with adult checklists provide a promising avenue for future validation of the SPA checklists. This article will review the developmental steps in producing the SPA crisis checklists, including creation of content, incorporation of human factors elements, and validation in simulation. Critical-events checklists have the potential to improve patient care during emergency events, and it is hoped that incorporating the elements presented in this article will aid in successful implementation of these essential cognitive aids.

Intravenous versus inhalational techniques for rapid emergence from anaesthesia in patients undergoing brain tumour surgery: A Cochrane systematic review

Abstract Background: Early and rapid emergence from anaesthesia is desirable for most neurosurgical patients. With the availability of newer intravenous and inhalational anaesthetic agents, all of which have inherent advantages and disadvantages, we remain uncertain as to which technique may result in more rapid early recovery from anaesthesia. The objective of this review was to assess the effects of intravenous versus inhalational techniques for rapid emergence from anaesthesia in patients undergoing brain tumour surgery. Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 6) in The Cochrane Library, MEDLINE via Ovid SP (1966 to June 2014) and EMBASE via Ovid SP (1980 to June 2014). We also searched specific websites, such as www.indmed.nic.in, www.cochrane-sadcct. org and www.clinicaltrials.gov (October 2014). We included randomised controlled trials (RCTs) that compared the use of intravenous anaesthetic agents such as propofol and thiopentone with inhalational anaesthetic agents such as isoflurane and sevoflurane for maintenance of general anaesthesia during brain tumour surgery. Primary outcomes were emergence from anaesthesia (assessed by time to follow verbal commands, in minutes) and adverse events during emergence, such as haemodynamic changes, agitation, desaturation, muscle weakness, nausea and vomiting, shivering and pain. Secondary outcomes were time to eye opening, recovery from anaesthesia using the Aldrete or modified Aldrete score (i.e., time to attain score ≥9, in minutes), opioid consumption, brain relaxation (as assessed by the surgeon on a 4- or 5-point scale) and complications of anaesthetic techniques, such as intraoperative haemodynamic instability in terms of hypotension or hypertension (mmHg), increased or decreased heart rate (beats/min) and brain swelling. We used standardised methods in conducting the systematic review, as described by the Cochrane Handbook for Systematic Reviews of Interventions. We used a fixed-effect model when we found no evidence of significant heterogeneity between studies, and a random-effects model when heterogeneity was likely. Results: We included 15 RCTs with 1833 participants. We determined that none of the RCTs were of high methodological quality. For our primary outcomes, pooled results from two trials suggest that time to emergence from anaesthesia, that is, time needed to follow verbal commands, was longer with isoflurane than with propofol (mean difference [MD] –3.29 min, 95% confidence interval [CI] –5.41––1.18, low-quality evidence), and time to emergence from anaesthesia was not different with sevoflurane compared with propofol (MD 0.28 min slower with sevoflurane, 95% CI – 0.56–1.12, four studies, low-quality evidence). Pooled analyses for adverse events suggest lower risk of nausea and vomiting with propofol than with sevoflurane (risk ratio [RR] 0.68, 95% CI 0.51–0.91, low-quality evidence) or isoflurane (RR 0.45, 95% CI 0.26–0.78) and greater risk of haemodynamic changes with propofol than with sevoflurane (RR 1.85, 95% CI 1.07–3.17), but no differences in the risk of shivering or pain. Pooled analyses for brain relaxation suggest lower risk of tense brain with propofol than with isoflurane (RR 0.88, 95% CI 0.67–1.17, low-quality evidence), but no difference when propofol is compared with sevoflurane. Conclusions: The finding of our review is that the intravenous technique is comparable with the inhalational technique of using sevoflurane to provide early emergence from anaesthesia. Adverse events with both techniques are also comparable. However, we derived evidence of low quality from a limited number of studies. The use of isoflurane delays emergence from anaesthesia. These results should be interpreted with caution. RCTs based on uniform and standard methods are needed.

Functional cardiovascular assessment in dentists performing local anesthesia in out-patient settings

The article presents the results of the cardiovascular changes assessment using electrocardiography (ECG) monitoring during local anesthesia in GP dentists. Selective ECG monitoring was carried out in 60 dentists aged 25-55 years (1 group - 25-34 y.o.; 2 group - 35-44 y.o.; 3 group - 45-55 y.o.) by means of portable «Valens» system. The study of stress index or the index of regulatory systems tension (IT) was conducted for 6 hours in the first day half within 1 working day. IT from 50 to 150 relative units was considered normal. In the first group IT peak was observed at the time of expectation of clinically relevant anesthesia in upper and lower jaw, while in the second and third groups it was associated with pain reaction in the course of treatment despite of clinical signs of anesthesia in the maxilla (IT=20±5.3 and 231±1.4, correspondingly) and mandible (IT=213±2.7 and 223±2.6, correspondingly). In all groups greater IT correlated more with mandible anesthesia events.

Letter to the Editor.

Anesthesia Progress recently published an article titled “Comparing the Efficiencies of Third Molar Surgeries With and Without a Dentist Anesthesiologist.”1 The introduction of this retrospective analysis refers to an article published by Bennett et al2 in the Journal of the American Dental Association that asked the question as to the safety of deep sedation or general anesthesia in the dental office. In that article, the authors provide OMSNIC data, which has been shared at numerous meetings of the American Association of Oral and Maxillofacial Surgeons and American Dental Society of Anesthesiology. The numbers reported that of an estimated 39.4 million anesthetics administered over a 14-year period, there were 113 cases that resulted in death or brain injury, which is an occurrence of 1 injury per approximately 350,000 anesthetic procedures or 1 injury every 6.4 weeks. Oral and Maxillofacial Surgery National Insurance Company (OMSNIC) insures an estimated 80% of practicing surgeons. The authors, therefore, estimated that if the 20% of oral and maxillofacial surgeons not insured by OMSNIC had a comparable occurrence, the potential anesthetic morbidity and mortality would approach 1 occurrence every 5.4 weeks. Unfortunately, as Bennett et al stated, a national safety center in which anesthetic outcome is assessed is not available.Oral and maxillofacial surgery (OMS) has striven to provide optimal care for its patients. The numbers reported above have been provided over the years in conjunction with anesthetic safety presentations in which the specialty has openly assessed adverse outcomes and processes to take to avoid such in the future. Missing from those numbers is what transpires in the non-OMS offices. From the information available, Bennett et al estimated that the occurrence of morbidity and mortality in all dental offices exceeds 1 every 4 weeks. Reebye et al1 incorrectly quoted Bennett et al in attributing the occurrence of more than 1 death or brain injury every 4 weeks to OMS, in which the statement reflected an estimated occurrence in all dental offices. This was probably a conservative estimate, and the occurrence per week of anesthetic morbidity and mortality associated with enteral and parenteral sedation and general anesthesia in non-OMS offices is probably comparable to that which occurs in OMS offices with a significantly smaller number of anesthetics administered. Unfortunately, without any national data reserve reporting death or brain injury as well as adverse anesthetic events, the dental profession cannot completely learn from these occurrences to minimize their occurrence in the future.The authors chose to report the numbers in the manner reflected of occurrences per week. When reported as an occurrence of 1 per every 350,000 anesthetics, the perception is different than when reported as 1 every 5.4 weeks. The first numbers reflect the safe delivery of anesthetic care; the latter asks if there is anything that can be done to optimize care. The article wanted to put the focus on the need to not be complacent but to continue to advance the delivery of anesthesia, which the OMS specialty is doing with the focus on advancing simulation training and team development.Nobody desires to minimize the tragedy associated with an adverse outcome. The goal of patient care is to do no harm. Patient safety is critical to patient care. The dental patient is getting older, more medically compromised, and taking more medications. Dental education, however, is minimizing the importance and time allotted to biomedical sciences and their application in the didactic and clinical curriculum, yet there are those who are encouraging and facilitating individuals with inadequate medical foundation to provide anesthetic services with little training. We always applaud individuals to assess what and how they provide care. Reebye retrospectively assessed the care that he provided. As the article correctly stated, there is bias in a retrospective data assessment, and a prospective study would be required to provide any recommendation to determine if the difference in the anesthetic delivery system is both of clinical significance and not just statistically significant. We feel that the article by Reebye et al1 incorrectly used the morbidity and mortality data from our publication to establish a foundation against the OMS surgical anesthetic team. Various practice models exist within dentistry for the delivery of anesthesia from sedation to general anesthesia. Safe deep sedation and general anesthesia is provided in OMS offices daily. It is important, however, for all dentists to understand that safe anesthesia practice is dependent on the following: appropriate patient selection; selection of an appropriate anesthetic depth; use of appropriate monitoring (considering beneficial or necessary redundancy in respiratory monitoring)3; equipping the office with the appropriate emergency medications, supplies, and instrumentation (including cognitive aids to provide recall in crisis situations); and a well-trained surgical/anesthetic team4 that routinely participates in simulated emergencies.

MA05.02 Electromagnetic Navigation Bronchoscopy: A Prospective, Global, Multicenter Analysis of 1000 Subjects with Lung Lesions

Electromagnetic navigation bronchoscopy (ENB) may aid in accessing smaller, more peripheral lesions and hence facilitate earlier diagnosis. ENB may also provide a safer alternative to transthoracic biopsy, and allow adequate tissue capture for molecular testing, diagnosis, staging, and localization for surgery in a single anesthetic event. However, usage patterns, safety, and performance remain largely unexplored in a prospective, multicenter study. NAVIGATE is a global, prospective, multicenter study of ENB using the superDimension™ navigation system (Medtronic, Minneapolis). A pre-specified 1-month interim analysis was conducted on the first 1,000 primary cohort subjects enrolled at 29 centers in the United States and Europe. Enrollment and 2-year follow-up are ongoing. One-month follow-up was completed in 933/1,000 subjects. Of 1,000 procedures, ENB was intended for lung biopsy in 96.4%, to place fiducial markers in 21.0%, and for dye marking in 1.7% (multiple indications in 34.9%). Lymph node biopsies were attempted in 33.4% of procedures (322/334 using linear endobronchial ultrasound [EBUS]). General anesthesia was used in 79.7% and radial EBUS in 54.3%. Among 1,129 lung lesions, fluoroscopy was used in 90.1% and rapid on-site pathology evaluation in 683/1035 (66.0%). Median lesion size was 20.0 mm (interquartile range 16.0 mm). Most lesions were in the peripheral (62.6%) or middle (30.1%) lung thirds. A bronchus sign was present in 48.4% and 6.3% were ground glass. Navigation was subjectively considered successful in 1,036 lesions (91.8%). Site-reported pathology results were read as malignant in 452 lesions (43.6%), including 38.1% with primary lung cancer. Of 247 lesions with adenocarcinoma or unspecified non-small-cell lung cancer, 70 (28.3%) were sent for molecular testing with adequate tissue in 56/70 (80.0%). Primary lung cancer clinical stage was 52.9% I; 10.7% II, 18.9% III, and 17.3% IV. Preliminary non-malignant results were obtained in 444 lesions (42.9%). An additional 140 lesions (13.5%) were read as inconclusive. Longer follow-up is required to calculate the true negative rate and diagnostic yield. ENB-related pneumothorax was 4.9% (49/1,000) overall and 3.2% Grade ≥2 based on the Common Terminology Criteria for Adverse Events scale. The ENB-related Grade ≥2 bronchopulmonary hemorrhage and Grade ≥4 respiratory failures rates were 1.0% and 0.6%. Interim 1-month results suggest a low adverse event rate in the largest prospective, multicenter ENB study conducted to date. Continued enrollment and 2-year follow-up will elucidate the real-world utilization patterns, diagnostic yield, factors contributing to successful diagnosis, and the impact of ENB on lung cancer management.

Eficiencia del manejo laparoscópico vs. endoscópico en colelitiasis y coledocolitiasis. ¿Existe diferencia?

BackgroundConcomitant cholelithiasis and choledocholithiasis is a disease where incidence increases with age and can have serious complications such as pancreatitis, cholangitis and liver abscesses, but its management is controversial, because there are minimally invasive laparoscopic and endoscopic surgical procedures. ObjectiveTo compare the efficiency in the management of cholelithiasis and choledocholithiasis with laparoscopic cholecystectomy with common bile duct exploration vs cholangiopancreatography endoscopic retrograde+laparoscopic cholecystectomy. Material and methodRetrospective analysis of a five year observational, cross sectional multicenter study of patients with cholelithiasis and concomitant high risk of choledocholithiasis who were divided into two groups and the efficiency of both procedures was compared. Group 1 underwent laparoscopic cholecystectomy with common bile duct exploration and group 2 underwent cholangiopancreatography endoscopic retrograde+laparoscopic cholecystectomy. Results40 patients, 20 were included in each group, we found p=0.10 in terms of operating time; when we compared hospital days we found p=0.63; the success of stone extraction by study group we obtained was p=0.15; the complications presented by group was p=0.1 and the number of hospitalizations by group was p ≤ 0.05 demonstrating statistical significance. ConclusionsBoth approaches have the same efficiency in the management of cholelithiasis and choledocholithiasis in terms of operating time, success in extracting stone, days of hospitalization, postoperative complications and conversion to open surgery. However the laparoscopic approach is favourable because it reduces the number of surgical anaesthetic events and the number of hospital admissions.

Checklists and Multidisciplinary Team Performance During Simulated Obstetric Hemorrhage

(Int J Obstet Anesth. 2016;25:9–16) Postpartum hemorrhage (PPH) rates have increased in the United States and some other developed countries over the past several years. PPH is also one of the leading causes of maternal morbidity and mortality. In an attempt to address these problems and improve outcomes, there has been a major focus on the development of protocols and checklists for use during PPH episodes. Studies have shown that adherence to recommended protocols and procedures during critical anesthetic events are improved when checklists and/or cognitive aids are used. The aim of this study was to evaluate checklist use and multidisciplinary team performance during a simulation of major PPH after vaginal delivery.